The New Medicaid – patients and providers screwed again?
You tell me. Here is an email received from my biller this morning, some names changed for privacy:
Zoe in my office has spent a lot of time speaking to multiple people at PacificSource. Here is the summary of what she has learned.
1. PacificSource views the approval of Jane Doe’s care a mistake. They will not be granting further authorizations.
2. PacificSource is opposed to home births. Lorri can attempt to get a contract directly with PacificSource, but they may deny the contract on grounds that she is a home birth provider. She will most likely need an Oregon License to complete the contracting process with PacificSource.
3. PacificSource contends that they are not required to cover home births even if it is a benefit granted by Oregon Health Plan.
4. We will continue to fax authorization requests to PacificSource. This will generate a letter from PacificSource to the patient with the authorization denial. The patient has the right to start the appeal process at that point.
5. PacificSource is the only Managed Care Organization in the Columbia Gorge area. Patient’s in that area can no longer get straight Oregon Health Plan coverage. They are required to go through PacificSource.
I recommend that you stop accepting Oregon Health Plan and PacificSource clients until you have obtained a PacificSource contract.
Keep in mind that PacificSource will pay for a midwife with a lesser credential than mine, as long as the birth happens inside the doors of some facility, and in spite of the fact that I am an approved/preferred provider for home births under OHP. The rules do not matter if OHP shuffles you off to a subcontractor, which is what the new federal plans are all about. And you thought the new healthcare bill was going to help you? Welcome to a whole new reality. It will help alright; help make certain that no providers will be able to get claims paid, so they will be forced to refuse to give you care. Call your legislators, folks, and perhaps an attorney because it is time for a class-action suit.
March 12, 2013 - LCarr
Now it looks like the situation in Oregon is getting worse (just when you thought it couldn’t possibly be any worse, right?) for anyone on any kind of state policy. Everyone is getting pushed into managed care plans, and those HMO’s make up their own rules as they go along.
Why is that bad? Because the insurance companies duck under the safety (for them) of the Medicaid umbrella, which means that an enrolled provider like me who accepts a Medicaid patient can not bill the patient, but now the insurance company does not have to pay the provider, either. So the company is taking public funds to provide the coverage, then won’t pay out claims, so after taking our tax money they act like they are private industry and can just keep it because they wrote the loopholes; in other words, they are defrauding the public. The doctors, midwives, and other providers will be forced to stop accepting those patients or go bankrupt, and once again – quality and availability of care both plummet.
To make it worse, the Oregon midwifery license means little, especially if the midwife already has a license which is superior (in both training and authority, like a Washington or New York license), it costs a lot, and is no guarantee that a Medicaid enrolled provider will end up being paid just because the patient has Medicaid. Medicaid (OHP) already paid so little that it did not even reimburse the expenses for the level of care that I and many other midwives provide, but now it most likely will not pay at all. But the license, which only requires a CPM, is still expensive, and offers little benefits to anyone that I have been able to determine. Reciprocity is not offered by OHP to Washington providers, so I wonder: from where do they think the money comes to purchase a license in Oregon that is nothing but more alphabet soup after a provider’s name? It sure doesn’t come from working for Medicaid’s private subcontractors for free.
The way the situation stands now, I am going to drop Oregon Medicaid like a wormy apple. My standards are too high, I refuse to give half-assed care, and they just don’t pay. Clients on OHP can ask me for a sliding-scale fee, and I am happy to accommodate, because I would rather work at a loss for my client than work for free for some rip-off HMO.
Another problem is the word-play being used by both sides of this argument, over the definition of midwifery. There are many types and many levels of midwifery; some are not medical care and some are. Don’t tell me that the policy-makers writing the insurance rules are too stupid and easily confused to be able to determine the difference and pay accordingly; I just don’t buy that line.
If Oregon is interested in fixing what is rumored to be a problem with quality of care in the midwifery community (not a problem in the Gorge, but apparently it has been farther south), then outlawing “lay” midwives or regulating licensed midwives to death is not even part of the answer and would only exacerbate the problems; INCENTIVES are the answer! Make the Oregon license good for something besides wallpaper (more stringent training requirements, more professional authority, and guarantee paid claims), lower the cost of the license, and you will see more midwives wanting to comply. Carrot, not stick. Offer quality bonuses for good patient outcomes, and you will see the standards of care rising, fast. Isn’t that supposed to be the goal?
March 25, 2013 - LCarr